Payer Enrollment

Before submitting additional payer requests, please review the following:

  • The Third Party Claims module is required to electronically submit commercial claims.
  • The RelayHealth Payer List is available to review prior to submitting an Additional Payer Request.
    • View the RelayHealth Payer List here
    • Payers may still be requested if they are not represented on the payer list.
    • If RelayHealth does not have connectivity to the requested payer, an option to request connectivity will be offered.
  • Additional Payer Requests are processed in the order received.
  • Set up timeframes vary by payer.
  • Incomplete and inaccurate requests may cause a delay in setup. To prevent unnecessary delays, please provide as much information in the request as possible.




Facility Name:

Matrixcare Client ID:

ePREMIS CID:

Facility NPI:

Facility Tax ID:

Enrollment Contact:

Enrollment Contact Title:

Enrollment Contact Email:

Enrollment Contact Phone:

Enrollment Contact Fax:

Authorized Signer’s Name:

Authorized Signer’s Title:

Claims Management Payer Name:

LOB:

NEIC/Payer ID:

Provider ID/PTAN:

Form Type:

State Specific Managed Medicaid Program: